| NPI | 1215389259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2019013306) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2016023157) |
| Enumeration Date | 2016-07-01 |
| Last Update Date | 2019-09-09 |